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Hospital Discharge Report
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Admission evaluation
Mr. Reijer Wolff was admitted on April 20, 2025, following a fall that resulted in
a closed fracture of the tibia and fibula of the left leg.
| Problems | SNOMED |
|---|---|
| Fracture of lower leg, Left lower limb | 414292006 |
Procedures
On April 23, 2025, a fixateur externe was applied to stabilize the fracture. The procedure
was performed under general anesthesia without complications.
| Procedures | SNOMED |
|---|---|
| Application of external fixator device, Left lower limb | 304527002 |
Medications
The patient received paracetamol for pain relief and cefazolin as a prophylactic antibiotic
post-surgery.
| Medication administrations | SNOMED |
|---|---|
| Paracetamol | 387517004 |
| Cefazolin | 387458008 |
Hospital Course
The patient was monitored for signs of infection, received regular wound care, and
started physiotherapy during the stay. No adverse events occurred.
Discharge and Follow-up
Mr. Doe was discharged in stable condition with instructions to avoid weight-bearing
on the left leg and to follow up in the orthopedic clinic.